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_ - Waste Tire Sufty & Inspection Repor' Inspection Report Number <br />State of California <br />CIWMB181 <br />Waste <br />Survey Form - Page 1 LL 7- 1 0 0 8 0 2 3 <br />California Integrated Waste Management Board <br />Part A - Surve BLUE OR BLACK INK PEN <br />nspection Details imima <br />TPID -/ � ! ---7 Inspection Type (Fill one) <br />Site Suffix: (� ( 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physical- Address <br />Business Rep <br />Tire Count (Whole/PTE) <br />- _ <br />Inspection Date <br />HAULING AND MANIFEST REQUIREMENTS ' <br />0 <br />State � ZIP Code I <br />Title <br />Time In <br />_ _ 0 AM <br />Time Out <br />0 AM <br />0 <br />0 <br />O PM <br />' m O PM <br />V.- <br />Operational Status Tire Type <br />Business Role <br />_ <br />Storage Typ <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />l <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that app <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />f lJ <br />0 Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />j0 <br />0 <br />-T -10—,O <br />Closed <br />0 Altered <br />0 <br />Other: § <br />F <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS ' <br />0 <br />0 <br />PRC §42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />AiNEW <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datee/e/e <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />Inspection Form " he a e, . <br />Comments Included: 0 <br />Business Rep's Signature Phone Number/ <br />INSTRUCTIONS ON BACK Correct: Incorrect: X � v <br />White Copy: CIWMB Yellow Copy Operator <br />Inspector's Signature Phone Number <br />,E XIA'MIPILIEI 1! 2 3 62081 <br />Pink Copy: LEA <br />